Surgical instrument and method for performing a resection

ABSTRACT

An end effector for use with a surgical instrument comprising an anvil shaft, a first anvil assembly disposed at a distal portion of the anvil shaft and a second anvil assembly mountable on the anvil shaft proximally of the first anvil assembly. Also, a method for performing a surgical procedure is provided including the steps of providing a surgical instrument including a first cartridge assembly and a first anvil assembly having an anvil shaft, approximating the first anvil assembly and first cartridge assembly and ejecting staples from the first cartridge assembly. The method further includes removing the first cartridge assembly from the tubular organ, and inserting a second anvil assembly into the tubular organ to engage the anvil shaft of the first anvil assembly and ejecting staples from a second cartridge assembly towards the second anvil assembly.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a Divisional of U.S. patent application Ser. No.13/798,950 filed Mar. 13, 2013, which is a Divisional of U.S. patentapplication Ser. No. 12/770,182 filed Apr. 29, 2010, now U.S. Pat. No.8,418,909, which claims benefit of and priority to U.S. ProvisionalApplication No. 61/183,201 filed Jun. 2, 2009, and the disclosures ofeach of the above-identified applications are hereby incorporated byreference in their entirety.

BACKGROUND

Technical Field

The present disclosure relates generally to a surgical instrument and,more specifically, to a surgical instrument for clamping, cutting,and/or joining tissue.

Background of Related Art

Certain surgical stapling instruments are used for applying rows ofstaples through compressed living tissue. These surgical staplinginstruments are employed, for example, for fastening tissue or organsprior to transection or resection or during anastomoses. In some cases,these surgical stapling instruments are utilized for occluding organs inthoracic and abdominal procedures.

Typically, such surgical stapling instruments include an anvil assembly,a cartridge assembly for supporting an array of surgical staples, anapproximation mechanism for approximating the cartridge and anvilassemblies, and a firing mechanism for ejecting the surgical staplesfrom the cartridge assembly.

In use, a surgeon initially advances an alignment pin assembly andsubsequently approximates the anvil and cartridge assemblies. Next, thesurgeon can fire the instrument to the instrument to place staples intissue. Optionally, the surgeon may use the same instrument or aseparate device to cut the tissue adjacent or between the row(s) ofstaples.

SUMMARY

The present disclosure in one aspect relates to an end effector for usewith a surgical instrument comprising an anvil shaft, a first anvilassembly disposed at a distal portion of the anvil shaft, and a secondanvil assembly mountable on the anvil shaft proximally of the firstanvil assembly.

Preferably, the anvil assembly and anvil shaft are aligned by key slots.

In one embodiment, the first anvil assembly has a first plurality ofanvil pockets arranged in a substantially annular row to deformfasteners fired from a first fastener cartridge and the second anvilassembly has a second plurality of anvil pockets arranged in asubstantially annular row to deform fasteners fired from a secondfastener cartridge.

Preferably, each of the first anvil assembly and the second anvilassembly is slidable in response to movement of the anvil shaft. Thesecond anvil assembly can include a weakened portion that is configuredto break when a knife moves therethrough and the first anvil assemblycan have a knife receiving portion for embedding the knife when theknife moves through the second anvil assembly.

In some embodiments, the second anvil assembly is mountable to the anvilshaft after fasteners are deformed by the first anvil assembly.

In some embodiments, the anvil shaft is removably mountable to asurgical instrument having a cartridge containing a plurality offasteners and an actuator for firing the fasteners from the cartridge.

In another aspect, the present disclosure relates to a method forperforming a resection. This method includes the steps: providing asurgical instrument including a first cartridge assembly and a firstanvil assembly having an anvil shaft; inserting the first anvil assemblyinto a tubular organ; approximating the first anvil assembly toward thefirst cartridge assembly; ejecting staples from the first cartridgeassembly towards the first anvil assembly; removing the first cartridgeassembly from the tubular organ such that the first cartridge assemblyoperatively disengages the anvil shaft of the first anvil assembly;inserting a second anvil assembly into the tubular organ such that thesecond anvil assembly operatively engages the anvil shaft of the firstanvil assembly; and ejecting staples from a second cartridge assemblytowards the second anvil assembly.

The method can further include the step of inserting the first cartridgeassembly into the tubular organ such that the first cartridge assemblyoperatively engages the first anvil assembly prior to the step ofapproximating the first cartridge.

The method can further include the step of inserting a second cartridgeassembly into the tubular organ such that the second cartridge assemblyoperatively engages the second anvil assembly prior to the step ofapproximating the second cartridge.

BRIEF DESCRIPTION OF THE DRAWINGS

Various embodiments of the presently disclosed surgical instruments andmethods are disclosed herein with reference to the drawings, wherein:

FIG. 1 is a perspective view of a surgical instrument according to anembodiment of the present disclosure, the instrument used to fire asecond set of fasteners;

FIG. 2 is a longitudinal cross-sectional view of the surgical instrumentshown in FIG. 1;

FIG. 3 is a longitudinal cross-sectional view of a handle assembly ofthe surgical instrument shown in FIGS. 1 and 2, taken around section 3of FIG. 2;

FIG. 4 is a longitudinal cross-sectional view of a distal portion of thesurgical instrument shown in FIGS. 1 and 2, taken around section 4 ofFIG. 2;

FIG. 4A is a longitudinal cross-sectional view of a distal portion ofanother surgical instrument used to fire the first set of fasteners;

FIG. 5 is a perspective view of the surgical instrument shown in FIGS. 1and 2, illustrating a stage of operation of said surgical instrument;

FIG. 6 is a longitudinal cross-sectional view of a distal portion of thesurgical instrument shown in FIG. 1, depicting another stage ofoperation of said surgical instrument;

FIG. 7 is a longitudinal cross-sectional view of the handle assemblyshown in FIG. 3 being actuated;

FIG. 8 is a longitudinal cross-sectional view of the end effector shownin FIG. 4 shown being moved to the approximated position;

FIG. 9 is a longitudinal cross-sectional view of a tubular organ with acartridge assembly and a first anvil assembly of the surgical instrumentof FIG. 4A positioned therein, showing the first anvil assembly securedinside the tubular organ with a pursestring suture;

FIG. 10 is a longitudinal cross-sectional view of the tubular organshown in FIG. 9 during irrigation after the cartridge assembly depictedin FIG. 4A has been removed from the tubular organ;

FIG. 11 is a longitudinal cross-sectional view of the tubular organshown in FIG. 9 with the first anvil assembly and a second anvilassembly positioned therein, and a pursestring suture wrapped around aportion of the tubular member located between the first anvil assemblyand the second anvil assembly;

FIG. 12 is a perspective view of an anvil shaft and the second anvilassembly shown in FIG. 11 in cross-section;

FIG. 13 is a longitudinal cross-sectional view of the tubular organshown in FIG. 9 with the first anvil assembly, the second anvilassembly, and the cartridge assembly of the surgical instrument of FIG.1 positioned therein, showing the surgical instrument beforeapproximation and firing;

FIG. 14 is a longitudinal cross-sectional view of the tubular organshown in FIG. 9 with the first anvil assembly, the second anvilassembly, and the cartridge assembly of the surgical instrument of FIG.1 positioned therein, showing the surgical instrument after it has beenapproximated and fired; and

FIG. 15 is a longitudinal cross-sectional view of the tubular organshown in FIG. 9 after the surgical instrument has been fired and removedfrom the tubular organ.

DETAILED DESCRIPTION OF THE EMBODIMENTS

Embodiments of the presently disclosed surgical instrument and methodare described in detail with reference to the drawings, wherein likereference numerals designate corresponding elements in each of theseveral views. In the description that follows, the term “proximal”refers to the end or portion of the surgical instrument closer to theclinician, whereas the term “distal” refers to the end or portion of thesurgical instrument further away from the clinician.

FIGS. 1 and 2 illustrate an embodiment of the presently disclosedsurgical instrument 10 when both first and second anvil assemblies arepositioned on the anvil shaft. As will be described in more detailbelow, a first instrument is used for firing a first set of fastenerswith respect to a first anvil assembly. The first instrument is thenseparated from the anvil assembly and removed from the body. The secondanvil assembly is then inserted onto the anvil shaft of the first anvilassembly and a second instrument is utilized to fire a second set offasteners with respect to the second anvil assembly. FIG. 1 illustratesthe second instrument used to fire fasteners against second anvilassembly 32; FIG. 4A illustrates a portion of the first instrument usedto fire fasteners against first anvil assembly 30. As shown in FIGS. 1and 2, the first anvil assembly 30 is positioned distally of the secondanvil assembly 32.

In the interest of brevity, the present disclosure focuses on endeffectors for the disclosed second surgical instrument 10. U.S. Pat. No.7,303,106, the entire contents of which are hereby incorporated byreference, describes in detail the structure and operation of anembodiment of surgical instrument 10.

Turning first to the second surgical instrument and with reference toFIGS. 1 and 2, in general, the second surgical instrument 10 includes ahandle assembly 12, an elongated central body portion 14 including acurved elongated outer tube 14 a, and an end effector or distal head orend portion 16. Elongated central body portion 14 extends distally fromhandle assembly 12 and operatively couples end effector 16 to handleassembly 12. In operation, end effector 16 fires fasteners into anvilassembly 32, deploys a cutting device 62 (FIG. 8), or both, uponactuation of handle assembly 12.

Handle assembly 12 includes a stationary handle 18, a firing trigger 20,a rotatable approximation knob 22 and an indicator 24. In certainembodiments, stationary handle 18 is made of a thermoplastic, such aspolycarbonate. In other embodiments, stationary handle 18 is formed ofan elastomeric material. Stationary handle 18 may nevertheless be formedof any suitable material. In some embodiments, stationary handle 18 hasa hollow body that houses internal components of handle assembly 12.U.S. Pat. No. 7,303,106, the entire contents of which have already beenincorporated by reference, describes in detail the internal componentsof handle assembly 12.

Handle assembly 12 further includes a trigger lock 26 for preventing, orat least minimizing, the risk of inadvertently firing surgicalinstrument 10. In the embodiment depicted in FIG. 1, trigger lock 26 ispivotally mounted to stationary handle 18. During use, trigger lock 26is configured to move relative to stationary handle 18 between a lockedposition and an unlocked position. In the locked position, trigger lock26 engages firing trigger 20 and precludes, or at least hinders,movement of firing trigger 20 with respect to stationary handle 18. Inthe unlocked position, trigger lock 26 allows firing trigger 20 to moveor pivot relative to stationary handle 18. Stationary handle 18additionally includes an indicator 24 to indicate to a clinician whetherend effector 16 is approximated and/or is ready to be fired. In someembodiments, indicator 24 has a bulbous or convex shape extendingoutwardly from a top surface of stationary handle 18. Stationary handle18 also includes approximation knob 22 operatively coupled to endeffector 16. Approximation knob 22 is configured to rotate with respectto stationary handle 18. A rotation of approximation knob 22 relative tostationary handle 18 causes end effector 16 to move between an openposition (FIG. 4) and an approximated position (FIG. 6).

End effector 16 generally includes a cartridge assembly 28, a firstanvil assembly 30 having an anvil shall 34 and a second anvil assembly32 slidably mountable on the anvil shaft 34. Cartridge assembly 28houses an array of fasteners, such as staples, and is configured toeject those fasteners in a distal direction into engagement with anvilpockets on second anvil assembly 32 (As noted above, anvil assembly 30receives fasteners of a different surgical instrument). Cartridgeassembly 28 includes slots 29 (FIG. 4) dimensioned to receive thefasteners 74 (FIG. 4). Slots 29 may be arranged in one or moresubstantially annular rows or in any other suitable configuration.

Turning now to the first anvil assembly 30, anvil assembly 30 includes ablunt or round distal head 36 and a tubular member 40 and is configuredto receive fasteners of the first surgical instrument of FIG. 4A. Morespecifically, with reference to FIGS. 1 and 4A, tubular member 40 ismovable with respect to distal head 36. In some embodiments, a biasingmember, such as a spring 99, biases tubular member 40 in a proximaldirection. Tubular member 40 defines a lumen configured to receive anvilshaft 34. Distal head 36 includes a circumferential groove 38 adapted toreceive a purse string suture. Groove 38 surrounds distal head 36 andmay have a concave configuration. Distal head 36 further includes aproximal surface 42 located proximally relative to groove 38. Proximalsurface 42 has a plurality of anvil pockets 41 adapted to receive anddeform fasteners 174 ejected from cartridge assembly 128 of the firstsurgical instrument. In disclosed embodiments, proximal surface 42 ismade of a metal, such as stainless steel or aluminum. In someembodiments, these pockets are arranged in one or more substantiallyannular rows on proximal surface 42. Other arrangements are contemplatedto correspond to arrangements of the fastener slots 129.

Anvil shaft 34 extends proximally from first anvil assembly 30 and has aproximal end 46 and a distal end 44. Distal end 44 of anvil shaft 34 isattached to first anvil assembly 30, whereas proximal end 46 of anvilshaft 34 is configured to be releasably coupled to the rod extendingfrom the cartridge assembly 128. Anvil shaft 34 additionally includeslongitudinal keys 48 extending between proximal end 46 and distal end44. Longitudinal keys 48 are configured to engage second anvil assembly32 to guide the translation of second anvil assembly 32 along anvilshaft 34. In use, longitudinal keys 48 block, or at least hinder,rotation of second anvil assembly 32 relative to anvil shaft 34.

Turning now to second anvil assembly 32, configured for use with thesecond surgical instrument of FIG. 1, and with reference to FIGS. 1, 4and 12, second anvil assembly 32 includes a tubular member 50 and a ring52 disposed around tubular member 50. Tubular member 50 has a proximalend 54 and a distal end 56. In addition, tubular member 50 includes aguide 60 adapted to guide a knife or any suitable cutting device 62deployed from cartridge assembly 28 of instrument 10. In certainembodiments, guide 60 has a tubular shape and defines a longitudinalopening 64 configured to slidably receive anvil shaft 34. In someembodiments, guide 60 includes one or more slots (not shown) disposedalong an inner surface thereof. The slots (not shown) of guide 60 areadapted to engage longitudinal keys 48 of anvil shaft 34. The engagementbetween longitudinal keys 48 and the slots of guide 60 facilitate axialtranslation of second anvil assembly 32 along anvil shaft 34, whileprecluding, or at least inhibiting, rotation of second anvil assembly 32relative to anvil shaft 34. Guide 60 defines an annular space 66.Annular space 66 is dimensioned to receive cutting device 62 and isdisposed adjacent a weakened or breakable portion 68 of tubular member50. Weakened portion 68 may be made of a polymer or any materialsuitable to break upon passage of cutting device 62 therethrough.Cutting device 62 is made of a metal, such as stainless steel oraluminum, or any material suitable to cut tissue. Weakened portion 68 isdisposed adjacent distal end 56 of tubular member 50. The break awayportion of anvil assembly 32 can pass through the body or otherwise becaptured and removed from the body.

Ring 52 is positioned around distal end 56 of tubular member 50 and hasa proximal surface 70 and a distal surface 72. In some embodiments, ring52 is made of metal, such as stainless steel or aluminum, or any othermaterial suitable to deform fasteners 74 ejected from cartridge assembly28. In some embodiments, proximal surface 70 of ring 52 includesfastener deforming pockets or concavities 71 configured to deformfasteners 74 deployed from cartridge assembly 28 of the second surgicalinstrument 10 upon contact with the pockets.

With reference to FIGS. 3-8, firing trigger 20 is operatively coupled toa fastener pusher 73 (FIGS. 4 and 6) positioned inside first cartridgeassembly 28. In several embodiments, surgical instrument 10 includes afiring link assembly 75 (FIG. 3) operatively interconnecting firingtrigger 20 and fastener pusher 73. Firing link assembly 75 extends fromhandle assembly 12 to cartridge assembly 28. In operation, actuation offiring trigger 20 causes a distal translation of fastener pusher 73 dueto distal translation of firing link assembly 75. Fastener pusher 73includes one or more fingers 77 (FIG. 4) dimensioned to be received inslots 29 of first cartridge assembly 28. When fastener pusher 73 movesdistally in response to an actuation of firing trigger 20, fingers 77move distally toward slots 29 and urge fasteners 74 toward second anvilassembly 32.

With continued reference to FIGS. 3-8, surgical instrument 10 furtherincludes an approximation link assembly 89 operatively couplingapproximation knob 22 to anvil shaft 34. As seen in FIG. 4,approximation link assembly 89 includes a rod or shaft 91 protrudingdistally from cartridge assembly 28. Rod 91 is disposed in mechanicalcooperation with anvil shaft 34 (e.g., in a friction-fit relationship).In certain embodiments, anvil shaft 34 defines a longitudinal opening 93dimensioned to receive rod 91. Longitudinal opening 93 extends through aproximal portion 95 of anvil shaft 34. In operation, a rotation ofapproximation knob 22 effects a translation of approximation linkassembly 89. Rotation of knob 22 rotates an internal screw which isoperatively connected to link assembly 89 via pin 87 to thereby movelink assembly 89 in a proximal or distal direction, depending on thedirection of rotation of knob 22. As approximation link assembly 89translates, rod 91 moves proximally or distally as it is connected tolink assembly 89 via pins 92. Since rod 91 is coupled to anvil shaft 34,movement of rod 91 causes anvil shaft 34 to move as well. While anvilshaft 34 moves, second anvil assembly 32 correspondingly moves in adistal or proximal direction.

It should be noted that similarly, when rod 191 of first instrument 110of FIG. 4A moves, it moves anvil shaft 34 to move first anvil assembly30 in a proximal or distal direction. That is, a user may approximatefirst anvil assembly 30 to cartridge assembly 128 by rotating anapproximation knob (similar to approximation knob 122 of FIG. 1) in afirst direction (e.g., clockwise). In response, the approximation linkassembly moves proximally and urges rod 191 in a proximal direction. Asrod 191 moves proximally, anvil shaft 34 translates proximally and pullsfirst anvil assembly 30 toward cartridge assembly 128 from an openposition to an approximated position, as described in detail below.

Referring back to the second instrument, as shown in FIG. 4, cartridgeassembly 28 of the second surgical instrument further may include aknife blade, or any suitable cutting device 62 movable between aretracted or proximal position and a deployed or distal position. Insome embodiments, knife 62 is operatively connected to fastener pusher73 and may have an annular configuration or shape. Knife 62 may be madeof a metal, such as stainless steel. In the retracted position, knife 62is positioned within cartridge assembly 28. In the deployed position,knife 62 is at least partially positioned outside of cartridge assembly28. While knife 62 moves between the retracted and deployed positions,at least a portion of knife 62 passes through an annular space 66defined in second anvil assembly 32 and through breakable annularportion 68, as discussed below.

With continued reference to FIG. 4, second anvil assembly 32 is slidablypositioned on anvil shaft 34 and includes annular space 66 defined intubular portion 50. Annular space 66 surrounds longitudinal opening 64and is dimensioned to receive knife 62. During use, annular space 66guides the translation of knife 62 through second anvil assembly 32.Second anvil assembly 32, as discussed above, also includes a breakableor weakened annular portion 68 substantially axially aligned withannular space 66. Breakable annular portion 68 may be made of ceramic,plastic, or any other suitable material and is positioned distally ofannular space 66. Breakable annular portion 68 is made of a materialthat can be broken by knife 62 during the firing process. As knife 62moves from the retracted position to the deployed position, knife 62passes through annular space 66 of second anvil assembly 32 and thenbreaks breakable annular portion 68 of second anvil assembly 32. Afterknife 62 breaks through breakable annular portion 68, knife 62 continuesmoving toward first anvil assembly 30 wherein it becomes embedded. Morespecifically, first anvil assembly 30, coupled to anvil shaft 34,includes tubular portion 40 having a proximal surface 101. Proximalsurface 101 of tubular portion 40 serves as a knife cutting target. Assuch, proximal surface 101 of tubular portion 40 receives knife 62 andstops further distal translation of knife 62 during the firing processas the knife becomes embedded therein. The anvil assembly 30 can includea cut ring.

Cutting device 62 is configured to move between a proximal or retractedposition and a distal or deployed position. In the retracted position,cutting device 62 is positioned inside cartridge assembly 28, whereas,in the deployed position, cutting device 62 is at least partiallypositioned outside of cartridge assembly 62. In some embodiments,cutting device 62 moves from the retracted position to the deployedposition concomitantly with distal advancement (firing of) the fastenersupon actuation of handle assembly 12. In other embodiments, cuttingdevice 62 can be selectively advanced independently of the fastenersstored in cartridge assembly 28. In these embodiments, the clinician caneject the fasteners housed in cartridge assembly 28, while maintainingcutting device 62 in the retracted position. Subsequently, cuttingdevice 62 would be actuated.

With reference to FIGS. 9-15, the method of use of the surgicalinstruments disclosed herein to cut, fasten, and/or join tissue in anumber of surgical procedures is disclosed. For example, surgicalinstrument 10 may be employed in a lower anterior resection where it isdesirable to clamp an upper portion of the bowel for cleaning the rectumprior to resection and joining the two tissue sections.

In one exemplary procedure, a clinician inserts first anvil assembly 30along with anvil shaft 34 into a tubular vessel or organ “O”, such asthe intestine (see FIG. 9). First anvil assembly 30 may be inserted intothe intestine through a patient's anus. Irrespective of the insertionmethod, first anvil assembly 30 may be positioned, for example, adjacenta tumor. In particular, first anvil assembly 30 may be placed justdistally of the tumor. After placing the first anvil assembly 30 in thedesired site, the clinician fixes the position of first anvil assembly30 relative to tubular organ “O.” To fix the position of first anvilassembly 30, the clinician may wrap a purse string suture “S1” around aportion of tubular organ located around groove 38, as shown in FIG. 9.Then, the clinician tightens string “S1” to secure first anvil assembly30 within tubular organ “O.” Alternatively, the clinician secures firstanvil assembly 30 inside tubular organ “O” with a mechanical clamp.

Once first anvil assembly 30 has been secured to tubular organ “O,” theclinician inserts the first surgical instrument 110 of FIG. 4Acontaining cartridge assembly 128 into tubular organ “O” such thatcartridge assembly 128 operatively engages first anvil assembly 30.Specifically, the clinician advances cartridge assembly 128 throughtubular organ “O” and cartridge assembly 128 is operatively connected toanvil shaft 34 via rod or (anvil retainer), 191, as seen in FIG. 9. Ascan be appreciated, at this point second anvil 32 has not yet beenattached to anvil shaft 34. Cartridge assembly 128 may be inserted intothe subject's intestine through the anus. Cartridge assembly 128includes a plurality of fasteners for contact with the anvil pockets ofanvil assembly 30, but preferably does not include a knife.

After operatively coupling cartridge assembly 128 of first surgicalinstrument 110 (of FIG. 4A) with first anvil assembly 30, the cliniciandraws a portion of the tubular organ “O” located between first anvilassembly 30 and cartridge assembly 28 toward anvil shaft 34, asillustrated in FIG. 10. To pull said portion of tubular organ “O” towardanvil shaft 34, the clinician wraps a purse string suture “S2” aroundsaid portion of tubular organ and then tightens string “S2.” The anvilassembly 30 is then approximated toward the cartridge assembly 128 byrotation of an approximation knob (not shown) similar to rotation knob22 of instrument 10. Subsequently, the clinician actuates a handleassembly (not shown) similar to handle assembly 12 of instrument 10 toeject fasteners 174 stored inside cartridge assembly 128 to fasten theportion of tubular organ pulled with string “S2.” Upon actuation of thehandle assembly (similar to handle assembly 12 of FIG. 1), fasteners 174are ejected from cartridge assembly 128 and move toward first anvilassembly 30, penetrating the portion of the tubular organ locatedbetween cartridge assembly 128 and first anvil assembly 30. Whenfasteners 174 reach pockets 41 on proximal surface 42 of first anvilassembly 30, fasteners 174 deform and fasten the portion of the tubularorgan “O” located between cartridge assembly 128 and first anvilassembly 30. The clinician then moves end effector 16 back to the openposition (e.g., by rotating the approximation knob in the oppositedirection), disengages cartridge assembly 128 from anvil shaft 34 byseparating shaft 191 from anvil shaft 34, and removes cartridge assembly128 from tubular organ “O” and instrument 110 from the patient's body,leaving first anvil assembly 30 inside tubular organ “O.” Tubular organ“0” may then be irrigated to clear said section from debris and tumorcells, as schematically shown in FIG. 10 by dashed lines “I.” In oneexemplary process, the clinician irrigates the anorectal canal withwater or a saline solution.

Next, the clinician inserts second anvil assembly 32 into tubular organ“O” and slides second anvil assembly 32 over anvil shaft 34, as shown inFIGS. 11 and 12. Second anvil assembly 32 may be inserted, for example,through the subject's anus. Longitudinal keys 48 guide the placement ofsecond anvil assembly 32 along anvil shaft 34. The clinician theninserts cartridge assembly 28 of a second surgical instrument 10 (showne.g. in FIGS. 1 and 4) containing a cutting device 62 into the tubularorgan “O.” This cartridge assembly 28 may be similar to the cartridgeassembly 128 that was inserted previously except cartridge assembly 28has a cutting device 62 capable of moving independently of thefasteners. Alternatively, the clinician may insert a cartridge assembly28 different from the cartridge assembly 128 inserted previously. In anycase, the clinician may insert cartridge assembly 28 through thesubject's anus. Cartridge assembly 28 is advanced through tubular organ“O” until cartridge assembly 28 operatively engages anvil shaft 34 (FIG.13) due to the engagement of rod 191. It should be appreciated thatinstead of using two separate instruments 10, 110, it is alsocontemplated that the instrument can be provided with a removablecartridge so that the same instrument can be used to fire fasteners 174and fasteners 74, with a first cartridge for firing fasteners 174 nothaving a knife and after use, it is removed and replaced with a secondcartridge for firing fasteners 74 and having a knife.

After operatively coupling the second instrument 10 with anvil shaft 34,the clinician draws a portion of tubular organ “O” located between firstanvil assembly 30 and second anvil assembly 32 toward anvil shaft 34. Topull said portion of tubular organ “O,” the clinician may wrap a pursestring suture “S3” around said portion of tubular organ “O” and thentightens string “S3” (FIG. 13) to draw the portion of tubular organlocated between first anvil assembly 30 and second anvil assembly 32toward anvil shaft 34. A portion of tubular organ “O” located betweensecond anvil assembly 32 and cartridge assembly 28 is pulled towardanvil shaft 34. In one exemplary method, the clinician wraps a pursestring suture “S4” (FIG. 13) around said portion of tubular organ “O”and tightens string “S4” to draw the portion of tubular organ “O”located between second anvil assembly 32 and cartridge assembly 28toward anvil shaft 34. Thereafter, the clinician rotates approximationknob 22 to move end effector 16 to the approximated position, e.g.approximate anvil assembly 30 and cartridge 28, thereby clampingportions of tubular organ “O.” Then, the clinician actuates handleassembly 12 to eject fasteners 80 housed in cartridge assembly 28 and tomove cutting device 62 from the retracted position to the deployedposition, as depicted in FIG. 7. Fasteners 80 may move sequentially orconcomitantly with cutting device 62.

Upon actuation of handle assembly 12, fasteners 80 pass through theportion of the tubular organ located between cartridge assembly 28 andsecond anvil assembly 32 and reach proximal surface 70 of ring 52. Whenfasteners 80 reach the pockets 71 of proximal surface 70, fasteners 80deform and seal the portion of tubular portion located between cartridgeassembly 28 and second anvil assembly 32.

While cutting device 62 moves from the retracted position to thedeployed position, cutting device 62 passes through annular space 66 andbreaks through weakened portion 68 of second anvil assembly 32 to reachtubular member 50 of first anvil assembly 30. After breaking weakenedportion 68 of second anvil assembly 32 (FIG. 14), cutting device 62 cutsthe portion of the tubular organ “O” located between first anvilassembly 30 and second anvil assembly 32. When cutting device 62 engagestubular member 40, cutting device 62 may urge tubular member 40 distallyagainst the influence of the biasing member 99 of first anvil assembly30. It is envisioned that cutting device 62 cuts the portion of tubularorgan “O” containing the tumor.

Finally, the clinician moves end effector 16 to the open position byrotating approximation knob 22 and removes cartridge assembly 28, firstanvil assembly 30, and second anvil assembly 32 from tubular organ “O.”Any loose sections of second anvil assembly 32 may be removedindividually or may pass through the body. After completing the surgicalprocedure, tubular organ “O” has been cut in two sections A and B withsealed edges C and D, as seen in FIG. 15.

Thereafter, a circular anastomosis instrument can be inserted throughthe lower tissue portion and into the tubular organ O. The instrument isclamped to approximate the two portions (since a tissue portion inbetween has been removed) and then staples are fired to join theportions.

Thus, as can be appreciated, one use of the instrument is in a loweranterior resection procedure. Clamping of the tissue organ O above theintended resection area enables wash out (cleaning out) of the areabelow the clamping, with stapling occurring below the clamping. This isachieved with access through the anus of the patient.

While the above description contains many specifics, these specificsshould not be construed as limitations on the scope of the presentdisclosure, but merely as illustrations of various embodiments thereof.Therefore, the above description should not be construed as limiting,but merely as exemplifications of various embodiments. Those skilled inthe art will envision other modifications within the scope and spirit ofthe disclosure.

1-17. (canceled)
 18. A method of performing a surgical procedure,comprising: positioning a first anvil assembly into a tubular organ, thefirst anvil assembly including an anvil shaft; securing the first anvilassembly within the tubular organ; inserting a surgical instrument intothe tubular organ such that a first cartridge assembly of the surgicalinstrument operatively associates with the first anvil assembly;approximating the first anvil assembly and the first cartridge assembly;ejecting a first fastener from the first cartridge assembly toward thefirst anvil assembly; and removing the surgical instrument from thetubular organ such that first cartridge assembly disengages from thefirst anvil assembly and the first anvil assembly remains secured withinthe tubular organ.
 19. The method according to claim 18, whereinsecuring the first anvil assembly within the tubular organ includespositioning a first purse string around a first portion of the tubularorgan and the first anvil assembly.
 20. The method according to claim18, further comprising drawing a second portion of the tubular organlocated between the first anvil assembly and the first cartridgeassembly towards the anvil shaft, wherein drawing the second portion ofthe tubular organ includes positioning a second purse string around thesecond portion of the tubular organ.
 21. The method according to claim18, further comprising inserting a second anvil assembly into thetubular organ such that the second anvil assembly engages the anvilshaft of the first anvil assembly and is positioned proximally of thefirst anvil assembly.
 22. The method according to claim 21, furthercomprising inserting the surgical instrument into the tubular organ suchthat a second cartridge assembly of the surgical instrument engages theanvil shaft of the first anvil assembly and is positioned proximally ofthe second anvil assembly.
 23. The method according to claim 22, furthercomprising approximating the second cartridge assembly of the surgicalinstrument and the second anvil assembly, and ejecting a second fastenerfrom the second cartridge assembly toward the second anvil assembly. 24.The method according to claim 21, further comprising drawing a thirdportion of the tubular organ located between the first anvil assemblyand the second anvil assembly towards the anvil shaft, wherein drawingthe third portion of the tubular organ includes positioning a thirdpurse string around the third portion of the tubular organ.
 25. Themethod according to claim 22, further comprising drawing a fourthportion of the tubular organ located between the second anvil assemblyand the second cartridge assembly of the surgical instrument towards theanvil shaft, wherein drawing the fourth portion of the tubular organincludes positioning a fourth purse string around the fourth portion ofthe tubular organ.
 26. The method according to claim 23, furthercomprising cutting a portion of the tubular organ located between thefirst anvil assembly and the second anvil assembly.
 27. The methodaccording to claim 26, wherein cutting the portion of the tubular organincludes firing a knife of the second cartridge assembly into thetubular organ to move the knife from a proximal position towards adistal position.
 28. The method according to claim 27, wherein firingthe knife of the second cartridge assembly includes passing the knifethrough a portion of the second anvil assembly into contact with theportion of the tubular organ located between the first anvil assemblyand the second anvil assembly.
 29. The method according to claim 28,wherein passing the knife through the portion of the second anvilassembly includes breaking through a weakened section of the portion ofthe second anvil assembly when the knife moves from the proximalposition towards the distal position.
 30. The method according to claim18, further comprising irrigating an inner portion of the tubular organ.31. The method according to claim 23, wherein the first anvil assemblyand the second anvil assembly each includes at least one anvil pocketconfigured to deform the first fastener and the second fastener firedfrom the first cartridge assembly and the second cartridge assembly,respectively.
 32. The method according to claim 21, wherein the anvilshaft defines a longitudinal axis, and wherein the first anvil assemblyand the second anvil assembly are longitudinally aligned on thelongitudinal axis of the anvil shaft.